Bone Health Questionnaire

This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to bone health. It is not a substitute for professional medical advice from your health care provider.

Do you have low bone density or osteoporosis?*

Yes

No

Do you have a family history of osteoporosis? *

Yes

No

Have you lost height?*

Yes

No

Do you suffer from general poor health?*

Yes

No

Do you take any long-term medications known to increase the risk of osteoporosis (e.g., corticosteroids, heparin, anti-seizure medications)? *